Failure to Rescue

Prior to my being hired, a patient died from a pulmonary embolism after undergoing an orthopaedic surgical procedure to correct a fractured hip. The patient was young (in his 50’s) and although his respiratory decline and mental deterioration were noted, the staff failed to promptly recognize that a life threatening problem existed.

This incident was one of the driving forces in creating a Nurse Practitioner team to work with the Ortho-Trauma patients at our institution. The Ortho-Trauma med-surg floor consists of 45 beds (13 private) and has undergone vast staff turn over and internal change over the past 5 years. The total joint program (elective hip and knee replacements) moved to another facility transitioning this unit into one focusing on the growing number of ortho-trauma patients.

During my interview I asked one of the attending physicians why they specifically wanted Nurse Practitioners and not more Physician Assistants.

His blunt, unhesitating response? “I want nursing intuition.”

Fast forward to Memorial Day of this year. Staff was surprised when they saw me show up at 0600 on a day they assumed I had off. I knew that last Memorial Day, the resident on call had 39 consults (busy is 20). I also knew that the weather was going to be good. Imagine my lack of surprise when my patient census list hit 49 patients, more than 2/3rds new to me.

Mid point of the shift found me in the allied health room reviewing patient hospital course and status with one of the RNs. A family member of a fresh post-op patient approached the desk to relay their concern for the patient who, “wasn’t acting or breathing right.” The patient’s nurse, who was also in the room, said that she would be there in a minute, but looked unconcerned and unhurried. I quietly asked the nurse what the story was and was told the following:

• He had just been admitted from the PACU

• Diagnosis: BKA s/p unsalvageable ankle fracture/crush injury 5 days prior

• It was unknown to her how much pain medication had been given in the PACU

• He was in the SICU immediately prior to surgery

This was relayed to me while the RN sat in the chair making no move to go to the patient. I calmly asked for the chart, which was still with the patient. I suggested that we go down to the room and check him out together. On observation, he was pale, diaphoretic, lethargic, having periods of apnea (breathing only when stimulated), Alert and oriented x 0 and the family, to include the father, was in tears.

What would have happened had I not been eavesdropping?

In 2003, Sean Clarke and Linda Aiken from the Center for Health Outcomes and Policy Research at the University of Pennsylvania published the article, “Failure to Rescue.” (American Journal of Nursing, Jan. 2003, 103 (1), p. 42-47). They define ‘failure to rescue’ as “…clinicians’ inability to save a hospitalized patient’s life when he experiences a complication (a condition not present of admission).”

The idea of failure to rescue is based on the idea that many deaths which occur in hospitals are preventable. Common sense, AND RESEARCH, tells us that the nurse is the most important factor in the rescue success of these patients.

Kathy McCauley, President of the AACN, states that, “We [nurses] are the eyes, ears and hands of the health system every minute of every day.”

How can I, as a very green NP, convince the staff that without their diligence, patients will die?

In an entry from 10 July 2003, Azygos stated that:

“Nurses are not taught to do a primary and secondary survey…a primary survey evaluates the patient’s airway, breathing, and circulation. Sound familiar? A secondary survey is just that, a second look at the patient from head to toe after you make sure that the ABC’s have been addressed. Nurses do the same thing but it’s not taught this way and is not broken down this way in nursing school (although I think it should be). We waste more time in touchy-feely crap we could have spent in learning patient pathophysiology. It’s criminal. As a nurse practitioner you will have to alter your philosophy of patient care to include the mental steps of deciding on a medical plan of care.”

(Thanks to The NP Blog for the link)

Besides not processing that the patient needed to be urgently assessed when the family voiced their concern, the nurse didn’t think to IMMEDIATELY start the patient on oxygen when the pulse ox read 58%. Unfortunately, this is not the first time I have run into this lack of response to low pulse ox readings.

What happened to nursing intuition? Where is the critical thinking? Has it truly been lost in all of the ‘touchy-feely crap’ that Azygos mentioned?

In a recent conversation an attending physician expressed his nostalgia for the good ol’ days when the nurses took control, made decisions, and were proactive in patient care. He missed doing rounds and having the nurse tell him the over night events and point to where he needed to sign for the orders she wrote in his name. The confidence in the nursing staff is ceasing to exist.

How do I fight this tide of chaos and return the nurses to understanding that they are patient advocates?

I believe that this unit is at a very critical point. Trauma season has begun. Nurse-Patient ratios are getting better, but are still at almost dangerous levels. In leading by example, I know I need to follow the advice of Clarke and Aiken, teaching or reteaching nurses the following:

Surveillance:

• Frequent Assessments

• Acting on Patient Cues

• Recognize complications

Taking Action:

• Institute measures based on the ABCs

• Activate a team response (NP, physician, respiratory therapist, etc.)

• Anticipate equipment/information needs

• Administer life saving measures

It is my hope that this post is the beginning of a dialog. I am searching for answers to a seemingly insurmountable, and life threatening, set of circumstances. Where should I go now?

  1. I think that the nursing “intuition” is being smothered due to decreased clinical time required by nursing programs. I learned 90% of what I know on the job AFTER school was finished.. Most of what nursing schools teach now is how to pass the boards. I needed more reality and a nurse who would show me what mattered and how to pick up on the nuances of change from patient to patient. As nurses, we need to speak up to doctors when we know we are correct and not let them treat us as inferior healthcare providers. Once they trust our judgement, then we can practice properly. As for nurses who sit around and don’t monitor their patients, shame on them for disgracing the profession and one day they will be on the other side of the bed..

  2. I think that the nursing “intuition” is being smothered due to decreased clinical time required by nursing programs. I learned 90% of what I know on the job AFTER school was finished.. Most of what nursing schools teach now is how to pass the boards. I needed more reality and a nurse who would show me what mattered and how to pick up on the nuances of change from patient to patient. As nurses, we need to speak up to doctors when we know we are correct and not let them treat us as inferior healthcare providers. Once they trust our judgement, then we can practice properly. As for nurses who sit around and don’t monitor their patients, shame on them for disgracing the profession and one day they will be on the other side of the bed..

  3. that’s why it is scary to be a patient nowadays. the blame is not on the nurses alone, when they do not assess or care enough, but also on doctors who when paged, never call back right away, thinking “it must be just one of those senseless questions”. it is really sad.

  4. that’s why it is scary to be a patient nowadays. the blame is not on the nurses alone, when they do not assess or care enough, but also on doctors who when paged, never call back right away, thinking “it must be just one of those senseless questions”. it is really sad.

  5. I believe that one of the reasons that “nursing intuition” seems to be decreasing is that physicians (particularly residents in teaching programs) are so easy to get. Pagers and cellphones mean that someone to pass the buck to is only seconds away. This is taught in nursing school and results in the “it must be just one of those senseless questions” attitude on the part of the residents — which is a failing on their part as well as all those “MD aware” notes in the chart. I read those notes as “MD aware, I no longer care”. I don’t know how to fix this, and it’s sad because there’s noone better to work with than a trained, aggressive, interested nurse. That’s why I like working in the ICU so much — things happen so fast all the time that the buck can’t always be passed even at the speed of cellphone.

  6. I believe that one of the reasons that “nursing intuition” seems to be decreasing is that physicians (particularly residents in teaching programs) are so easy to get. Pagers and cellphones mean that someone to pass the buck to is only seconds away. This is taught in nursing school and results in the “it must be just one of those senseless questions” attitude on the part of the residents — which is a failing on their part as well as all those “MD aware” notes in the chart. I read those notes as “MD aware, I no longer care”. I don’t know how to fix this, and it’s sad because there’s noone better to work with than a trained, aggressive, interested nurse. That’s why I like working in the ICU so much — things happen so fast all the time that the buck can’t always be passed even at the speed of cellphone.

  7. If you are paging a doctor about a problem that needs to be dealt with IMMEDIATELY, then you should not be paging anyone at all, you should instead be calling a CODE BLUE

  8. If you are paging a doctor about a problem that needs to be dealt with IMMEDIATELY, then you should not be paging anyone at all, you should instead be calling a CODE BLUE

  9. wow, the comments on this have been great. I am just sad that I am only now responding to them.

    I agree with most of the things you all have posted. Critical thinking is gained by both mentorship and experience. When you have nurses with one year’s experience precepting due to high turn over, the problem becomes very cyclical.

    BladeDoc—your comment about passing the buck rings true at times, however I must have missed the day in nursing school when that explanation of the maneuver was given. I was actually taught in my first job that “MD aware” is a protective statement for nurses in regards to residents who like to ignore real patient issues. With that being said, in my role as an NP, I have seen the rash of abuse that is inherent in the system from both nursing and medical sides.

    How do we fix this? Hold each person accountable for doing their job. Nurses who pass the buck should be called out. MDs, Pas, NPs who don’t answer their pages should be called out.

    One last thing I want to comment on is NPSL’s statement:

    “As nurses, we need to speak up to doctors when we know we are correct and not let them treat us as inferior healthcare providers.”

    ABSOLUTELY!!!!!!!!!!!!

    I wanted to really, really respond more than that, but I will save that for a larger post. Thanks for the lead in NPSL! —- stay tuned for more on that topic.

  10. wow, the comments on this have been great. I am just sad that I am only now responding to them.

    I agree with most of the things you all have posted. Critical thinking is gained by both mentorship and experience. When you have nurses with one year’s experience precepting due to high turn over, the problem becomes very cyclical.

    BladeDoc—your comment about passing the buck rings true at times, however I must have missed the day in nursing school when that explanation of the maneuver was given. I was actually taught in my first job that “MD aware” is a protective statement for nurses in regards to residents who like to ignore real patient issues. With that being said, in my role as an NP, I have seen the rash of abuse that is inherent in the system from both nursing and medical sides.

    How do we fix this? Hold each person accountable for doing their job. Nurses who pass the buck should be called out. MDs, Pas, NPs who don’t answer their pages should be called out.

    One last thing I want to comment on is NPSL’s statement:

    “As nurses, we need to speak up to doctors when we know we are correct and not let them treat us as inferior healthcare providers.”

    ABSOLUTELY!!!!!!!!!!!!

    I wanted to really, really respond more than that, but I will save that for a larger post. Thanks for the lead in NPSL! —- stay tuned for more on that topic.

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